Statement of Potential Conflicts of Interest Continuous performance - - PowerPoint PPT Presentation

Statement of Potential Conflicts of Interest

Continuous performance test in ADHD and SUD patients (CASP) study

Relating to this presentation, the following relationships could be perceived as potential conflict of interests:

Nir Yacin and Adva (Peled) Levie are executives of Neurotech Solutions Ltd. Neurotech Solutions Ltd have analysed the following data and have provided partial funding of direct research costs.

Continuous performance test in ADHD and SUD patients (CASP) study

III International Congress on Dual Disorders, 24 Oct 2013

Sharlene Kaye1, Adva (Peled) Levie2, Nir Yacin2, Itai Berger3, Wim van den Brink4, Zsolt Demetrovics5, Máté Kapitány-Fövény5, Csaba Barta6, Brian Johnson7, Paulette Johnson7, Narelle Fordham1, Anneke Goudriaan4, Geurt van de Glind4,8

1 National Drug & Alcohol Research Centre, University of NSW, Australia; 2 Neurotech Solutions Ltd, Israel; 3 Hadassah-Hebrew University Medical Center, Israel; 4 Amsterdam Institute for Addiction Research, University

• f Amsterdam, The Netherlands;

5 Institute of Psychology, Eötvös Loránd University, Hungary; 6 Department of

Medical Chemistry, Molecular Biology and Pathobiochemistry, Semmelweis University, Hungary;

7Dept of

Psychiatry, SUNY Upstate Medical University, USA; 8Trimbos-instituut and ICASA Foundation, The Netherlands.

Background

ADHD diagnosis complicated by the heterogeneous nature & severity of ADHD symptoms & clinical presentations both within & between affected individuals. Majority of screening & diagnostic instruments are questionnaires or rating scales answered by parents, partners or teachers, or based on self-report. Lack of instruments that can measure specific deficits and measure change in the severity of symptoms. In an effort to provide objective measures of ADHD and characterise the underlying neurocognitive impairment, neuropsychological tests designed to measure specific areas of cognitive functioning (i.e. executive functioning) known to underlie attention, hyperactivity and impulsivity have been developed. Continuous Performance Tests (CPTs) have been considered by many to be the most reliable means of differentiating those with ADHD from those without

• ADHD. Widely used to complement structured clinical interviews and rating

scales as part of the “gold standard” for ADHD diagnosis.

Background

The available CPTs (e.g. TOVA, Conners’ CPT) measure attention, inhibitory/impulse control and reaction time, but have tended to yield high rates

• f false positives and false negatives.

Lack specificity with respect to relationship between results and specific ADHD symptoms and symptom domains (i.e. inattention, hyperactivity, impulsivity). Diagnosis based primarily on visual performance, ignoring other aspects of attention. As such, their validity and utility in the diagnosis of ADHD has been questioned.

Background

With these concerns & recommendations from previous research in mind, a new test designed to improve on the validity & utility of previous CPT designs has been developed. MOXO ADHD Test (Neurotech Solutions Ltd) – new generation of CPT designed to

• bjectively assess several domains of attention.

Compared to existing CPTs, the MOXO ADHD Test contains additional features that should improve the differential diagnosis process, producing more accurate results:

• Use of both visual and auditory distractors in the test. The distractors are complex video clips that have

both moving pictures and a sound track. The visual and auditory features are presented separately or together.

• Designed to match test items to the expected cognitive development of the individual, by having 2

versions, incorporating different visual & auditory items that are age appropriate - one version designed for children (7-12 yrs), the other for adolescents and adults (13+ yrs).

• Distinguishes in a given individual between the three main components of ADHD (Attention, Impulsivity &

Hyperactivity), as well as a novel fourth component of "Timing“, which measures reaction time of correct responses.

• Using these 4 measures, creates a specific and unique patient profile of difficulties & strengths, providing a

more nuanced understanding of the underlying features of ADHD in each individual.

Background

MOXO Test monitors the person’s ability to maintain attention throughout the whole test and any variability in performance in response to different distractors, thus indicating the conditions under which they perform best or worst. Individual results are compared to the standardized norms of groups of a similar age and gender. Validity studies have shown the MOXO Test to effectively differentiate between children with and without ADHD more effectively than traditional CPTs (TOVA

• r Conners’ CPT), with preliminary results of an international study of 547

children demonstrating 90% sensitivity and 86% specificity. May assist in tailoring treatment according to the current symptom presentation and severity.

Aims of CASP study

To test in a population of patients referred for Substance Use Disorders (SUD) the ability of the MOXO ADHD Test to -

• 1. Compare levels of attention, hyperactivity and impulsivity between patients

having SUD only, patients having SUD+ADHD, and a “normal” control group from the general population (no ADHD or SUD) in order to develop specific population norms for the psychometric properties of the MOXO;

• 2. Differentiate between SUD patients having ADHD and SUD patients not

having ADHD;

• 3. Evaluate how attention levels in those with ADHD compare to attention levels

in patients with other disorders, such as antisocial personality disorder, bipolar disorder, borderline personality disorder and depression.

Methods

Ø Sample

• 447 participants; Australia (107), Hungary (148), Ireland (9), U.S.A. (183)

Ø Recruitment

SUD patients – Recruited as part of IASP study from inpatient & outpatient addiction treatment services – e.g. residential rehabilitation; detox units, methadone clinics. Participants in the IASP study who completed the diagnostic assessment phase were asked to participate in the CASP study. Control group – Convenience sample recruited via advertising and word of mouth.

Methods

Ø Measures

SUD patients

• Structured interview:- As per IASP study + juvenile justice & prison history; past

head injury with loss of consciousness; methadone/buprenorphine dosage

• ASRS and diagnostic modules from MINI Plus and CAADID as per IASP study

+

• K-SADS – conduct disorder, oppositional defiant disorder, tobacco use
• Fagerstrom Test for Nicotine Dependence
• MOXO ADHD test

Control group

• Structured interview assessing demographics
• Screening instruments to exclude ADHD (ASRS) and SUD (CAGE-AID)
• MOXO ADHD test

Target Element Non Target Elements

Adult test

Distractors Visual / Audio / Combination

Adult test

MOXO attentiveness indices

ATTENTION- correct responses to stimulus TIMING- correct responses at correct time, i.e. during stimulus presentation HYPERACTIVITY- pressing more than once for a single stimulus IMPULSIVITY- commission errors performed during a non-target stimulus

Criteria Table

Performance graph

Preliminary Results

Age and gender characteristics by group

Controls/Norm (n=180) SUD (n=143) SUD+ADHD (n=115) ADHD (n=51) Mean age (SD) 32.8 (12.0) 39.7 (10.5) 33.5 (9.7) 28.8 (9.9) % Male 46 66 57 61

Timing

50 100 150 200 250 300 Norm SUD SUD+ADHD ADHD

M e a n T

• t

a l

Norm SUD SUD+ADHD ADHD

┌-----------------------***-----------------------┐ ┌-------------------------------------------**-----------------------------------------------┐ ┌------------------------------------------*--------------------------------------------------┐

*** p<.001; ** p<.01; * p<.05

Attention

50 100 150 200 250 300 350 400

M e a n T

• t

a l

Norm SUD SUD+ADHD ADHD

┌--------------------***------------------┐ ┌---------------------------------***--------------------------------------┐ ┌---------------------------------------------------**--------------------------------------------------------┐

*** p<.001; ** p<.01; * p<.05

Hyperactivity

10 20 30 40 50 60 70 80 90 100

Norm SUD SUD+ADHD ADHD

M e a n T

• t

a l

Norm SUD SUD+ADHD ADHD

┌-------------------------------------**--------------------------------------┐ ┌------------------------------------------------------*-------------------------------------------------------┐ ┌------------------**--------------------------┐

*** p<.001; ** p<.01; * p<.05

Impulsivity

10 20 30 40 50 60 70 80 90 100

M e a n T

• t

a l

Norm SUD SUD+ADHD ADHD

┌---------------------***--------------------┐ ┌--------------------------------------***--------------------------------------┐ ┌---------------------------------------------------------*--------------------------------------------------------┐

*** p<.001; ** p<.01; * p<.05

Predictor variables OR (95% CI) Age Gender (female) Timing Attention Hyperactivity Impulsivity 1.050 (1.03-1.08) 0.419 (0.26-0.69) 0.997 (0.99-1.01) 0.963 (0.93-0.99) 1.035 (1.01-1.06) 1.032 (1.00-1.06)

Logistic regression model predicting SUD group membership*

Predictor variables OR (95% CI) Age Gender (female) Timing Attention Hyperactivity Impulsivity 1.05 (1.03-1.08) 0.42 (0.26-0.69) 1.00 (0.99-1.01) 0.96 (0.93-0.99) 1.04 (1.01-1.06) 1.03 (1.00-1.06) *Reference group - Norm

Logistic regression model predicting SUD+ADHD group membership*

Predictor variables OR (95% CI) Age Gender (female) Timing Attention Hyperactivity Impulsivity 1.00 (0.98-1.03) 0.62 (0.38-1.03) 1.00 (0.99-1.01) 0.96 (0.93-0.99) 1.04 (1.01-1.06) 1.04 (1.01-1.07) *Reference group - Norm

Logistic regression model predicting ADHD group membership*

Predictor variables OR (95% CI) Age Gender (female) Timing Attention Hyperactivity Impulsivity 0.96 (0.92-0.99) 0.51 (0.26-0.99) 1.00 (0.99-1.01) 0.96 (0.92-0.99) 1.04 (1.01-1.06) 1.01 (0.98-1.05) *Reference group - Norm

Summary

• Performance on the MOXO test was significantly better among the control

(NORM) group compared to the SUD, SUD+ADHD and ADHD groups, with controls scoring higher in attention and lower in hyperactivity and impulsivity.

• No significant differences in attention, hyperactivity and impulsivity between the

SUD, SUD+ADHD and ADHD groups. Timing was poorest for SUD and SUD+ADHD groups.

• Lower levels of attention and higher levels of hyperactivity and impulsivity were

independently associated with being in the SUD and SUD+ADHD groups.

• Lower levels of attention and higher levels of hyperactivity were independently

associated with having ADHD only, but level of impulsivity was not a significant predictor.

Conclusions

• Preliminary results suggest the MOXO is able to discriminate between the

performance of adults from the general population and the performance of adults with SUD and/or ADHD.

• SUD and ADHD were associated with poorer attention and higher levels of

hyperactivity and impulsivity.

• Further analyses will be conducted to investigate differences between those

with ADHD and those with other psychiatric disorders, and to examine more closely MOXO performance between the SUD, SUD+ADHD and ADHD groups.

Acknowledgements: This research was funded by Neurotech Solutions Ltd and the ICASA

• Foundation. The authors wish to thank the participants for their time and the

staff at participating agencies for their assistance. Contact details: Dr Sharlene Kaye National Drug and Alcohol Research Centre University of New South Wales s.kaye@unsw.edu.au www.ndarc.med.unsw.edu.au NHMRC Centre for Research Excellence in Mental Health & Substance Use www.comorbidity.edu.au ICASA www.adhdandsubstanceabuse.org